What is the appropriate evaluation and treatment approach for a patient with suspected sinusitis and facial pain?

Diagnosing Tenderness in Sinusitis

Sinus tenderness is diagnosed through direct palpation over the affected sinuses during physical examination, with positive findings including pain elicited by pressure over the maxillary, frontal, or ethmoid regions, combined with clinical symptoms of purulent rhinorrhea, nasal congestion, and facial pain lasting more than 7-10 days. 1

Clinical Examination Technique

Physical Findings to Assess

• Direct palpation over sinuses: Apply gentle pressure over the maxillary sinuses (cheeks), frontal sinuses (forehead), and ethmoid sinuses (between eyes) to elicit tenderness 1
• Percussion tenderness: Tap over the maxillary teeth and malar eminences to assess for pain referral 1
• Visual inspection: Look for dark circles beneath the eyes, periorbital edema, facial swelling, or erythema over involved sinuses 1
• Nasal examination: Assess for mucosal erythema, purulent secretions, and nasal polyps (nasal endoscopy provides superior visualization compared to nasal speculum) 1
• Posterior pharynx: Examine for pharyngeal erythema, lymphoid hyperplasia, and purulent postnasal drainage 1

Symptom Duration and Pattern

The timing and pattern of symptoms distinguish viral from bacterial sinusitis and guide the need for further evaluation:

• Less than 10 days without worsening: Likely viral rhinosinusitis (VRS), does not require imaging or antibiotics 1
• 10-14 days or longer without improvement: Suspect acute bacterial rhinosinusitis (ABRS) 1
• "Double sickening" pattern: Initial improvement followed by worsening within 10 days strongly suggests ABRS 1
• Severe presentation: High fever (>39°C), purulent nasal discharge, and facial pain for 3-4 consecutive days warrants presumptive bacterial diagnosis 1

When Imaging is NOT Needed

Radiographic imaging is unnecessary for diagnosis when clinical criteria are already met because sinus involvement is common in viral upper respiratory infections, making it impossible to distinguish bacterial from viral sinusitis based solely on imaging. 1 Clinical criteria have comparable diagnostic accuracy to sinus radiography and are more cost-effective. 1

Plain radiographs have significant false-positive and false-negative results and should not be routinely obtained. 1

When Imaging IS Indicated

Obtain CT imaging (not plain films) in these specific situations:

• Suspected complications: Orbital swelling or pain, proptosis, diplopia, ophthalmoplegia, facial swelling/erythema over sinus, severe headache, cranial nerve palsies, or neurologic signs suggesting intracranial involvement 1
• Modifying factors: Diabetes, immunocompromised state, history of facial trauma or surgery 1
• Treatment failure: No response to appropriate antibiotic therapy after 3-5 days 1
• Chronic or recurrent disease: When considering surgical intervention or evaluating anatomic abnormalities 1

CT findings that correlate with bacterial sinusitis include opacification, air-fluid levels, and mucosal thickening greater than 6mm in adults (>4mm in children). 1

Red Flags Requiring Urgent Evaluation

Any patient presenting with these findings needs immediate specialist referral and imaging:

• Orbital involvement: swelling, pain, proptosis, abnormal extraocular movements, visual changes 1
• Facial swelling with erythema over an involved sinus 1
• Signs of intracranial extension: altered mental status, severe headache, meningeal signs 1
• Suspected invasive fungal sinusitis in immunocompromised patients: fever, facial pain progressing to facial necrosis, black necrotic areas on endoscopy 1

Associated Findings

• Ear examination: Middle ear effusions and eustachian tube dysfunction are frequently present 1
• Chest auscultation: Assess for asthma exacerbation, as sinusitis can trigger bronchial hyperresponsiveness 1
• Dental evaluation: Consider odontogenic source, as 20% of maxillary sinusitis may be dental in origin 1

Common Pitfalls to Avoid

• Over-reliance on imaging: Do not order CT scans for uncomplicated acute sinusitis meeting clinical criteria, as this adds cost without improving diagnostic accuracy 1
• Treating viral illness with antibiotics: Symptoms lasting less than 10 days without worsening are almost always viral and do not benefit from antibiotics 1
• Missing complications: Always examine for orbital and neurologic signs in patients with severe facial pain or tenderness 1
• Inadequate nasal examination: Use nasal endoscopy when available rather than relying solely on anterior rhinoscopy with a speculum 1